Clinical and Dermoscopic Approaches to Diagnosis of Frontal Fibrosing Alopecia: Results From a Multicenter Study of the International Dermoscopy Society.

INTRODUCTION: Frontal fibrosing alopecia (FFA) is a form of primary lymphocytic scarring alopecia characterized by a progressive recession of the fronto-temporal hairline. Although the clinical presentation of FFA is very typical, biopsy for histopathological examination is still recommended to confirm the diagnosis. Currently, a growing number of skin and mucosal inflammatory diseases are diagnosed with modern noninvasive techniques such as dermoscopy without the necessity of a biopsy. OBJECTIVES: The International Dermoscopy Society (IDS) aimed to test the ability of its members to diagnose classic FFA through clinical and dermoscopic parameters and to compare acquired data to the largest cohort studies published since 1994. METHODS: This is an observational, cross-sectional study describing patient demographics, clinical presentation and diagnostic tools used in a sample of FFA patients collected by IDS members. A literature search was then performed using Pubmed to review studies reporting more than 100 cases. RESULTS: IDS members submitted 188 cases demonstrating a predominant female population (98.4%). In 71.8% of the cases, the clinical presentation and the trichoscopic findings allowed for the diagnosis. Out of 24 revised studies, 13 showed that clinical and trichoscopic features were decisive for the diagnosis in almost all cases. CONCLUSIONS: Demographic and clinical data of our cohort were mostly comparable to previous reported data on FFA. The relevant role of the clinical and trichoscopic features in diagnosing FFA was confirmed by our study and the reviewed literature. Trichoscopy could be considered a worldwide-acknowledged non-invasive technique for the diagnosis of FFA.

Dermatoscopy of nodular/plaque-type primary cutaneous T- and B-cell lymphomas: A retrospective comparative study with pseudolymphomas and tumoral/inflammatory mimickers by the International Dermoscopy Society.

BACKGROUND: Limited data on dermatoscopy of nodular/plaque-type T-/B-cell primary cutaneous lymphomas (PCLs) is available. OBJECTIVE: To describe dermatoscopic features of nodular/plaque-type PCLs, comparing them with those of clinical mimickers (pseudolymphomas, tumors, and inflammatory lesions) and investigating possible differences according to histologic subtypes. METHODS: Participants were invited to join this retrospective, multicenter case-control study by submitting histologically/immunohistochemically confirmed instances of nodular/plaque-type PCLs and controls. Standardized assessments of the dermatoscopic images and comparative analyses were performed. RESULTS: A total of 261 lesions were included (121 PCLs and 140 controls). Orange structureless areas were the strongest PCL dermatoscopic predictor on multivariate analysis compared with tumors and noninfiltrative inflammatory dermatoses. On the other hand, a positive association was found between PCLs and either unfocused linear vessels with branches or focal white structureless areas compared with infiltrative inflammatory dermatoses, whereas white lines were predictive of PCLs over pseudolymphomas. Differences in the vascular pattern were also seen between B- and T-cell PCLs and among B-cell PCL subtypes. LIMITATIONS: Retrospective design and the lack of a dermatoscopic-pathologic correlation analysis. CONCLUSION: Nodular/plaque-type PCLs display dermatoscopic clues, which may partially vary according to histologic subtype and whose diagnostic relevance depends on the considered clinical differential diagnoses.

Value of Dermoscopy in a Population-Based Screening Sample by Dermatologists.

BACKGROUND: The use of dermoscopy improves the diagnosis of skin cancer significantly in trained dermatologists. However, to evaluate its cost-effectiveness in daily practice, not only sensitivity but also the excision rate is important. OBJECTIVE: We examined the diagnostic accuracy of cases from a true population-based sample scored by general dermatologists. METHODS: One hundred twenty-six dermatologists were randomly assigned to 145 digital cases of lesions detected at a skin cancer screening. This resulted in 4,655 case evaluations using a web application. Accuracy of diagnosis and treatment was correlated with the histological diagnosis or expert opinion. RESULTS: The larger portion (89.7%) of the participating dermatologists reported using their dermatoscope daily. The odds of making a correct diagnosis of melanoma using dermoscopy was 5.38 compared with naked-eye examination (NEE). Dermoscopy increased sensitivity for skin cancer diagnosis from 70.6% to 84.6%, but this was associated with a small but significant decrease in specificity of 3.5%. To detect 1 skin cancer, 5.23 lesions had to be biopsied/excised in this sample and this was not significantly improved by dermoscopic evaluation. Dermoscopy significantly increased the confidence about making a correct diagnosis, especially in seborrheic keratosis, Bowen disease, and melanoma. CONCLUSIONS: Dermoscopy significantly improved diagnostic accuracy, the sensitivity of skin cancer detection, and the confidence in diagnosis especially for seborrheic keratosis, Bowen disease, and melanoma. However, this finding was not reflected in a significant reduction in the number needed to excise in this sample.

Clinical Consequences of Antibody Formation, Serum Concentrations, and HLA-Cw6 Status in Psoriasis Patients on Ustekinumab.

BACKGROUND: Ustekinumab for the treatment of psoriasis is currently administered in a standard dosing regimen. However, some patients tend to benefit from alternative dosing regimens, a step toward personalized medicine. METHODS: To investigate the role of ustekinumab serum concentrations, anti-ustekinumab antibodies [AUA] and HLA-Cw6 status as tools for optimizing ustekinumab treatment, a multicenter prospective cohort study was conducted at an academic hospital with affiliated nonacademic hospitals in Belgium (cohort 1) and 2 academic hospitals in the Netherlands (cohort 2 and 3). Patients with plaque-type psoriasis were eligible if treated with ustekinumab for ≥16 weeks. Serum samples and Psoriasis Area and Severity Index scores were obtained at baseline, week 16, 28, 40, 52, and/or ≥64 of ustekinumab treatment. RESULTS: A total of 137 patients with 229 observations for serum concentrations and AUA and 61 observations for HLA-Cw6 status were included. Presence of AUA (prevalence of 8.7%) was significantly associated with a diminished clinical response (P = 0.032). The median ustekinumab trough concentration was 0.3 mcg/mL (<0.02-3.80). No differences in serum concentrations were observed between moderate to good responders and nonresponders (P = 0.948). Serum trough concentrations were not affected by methotrexate comedication. Prevalence of HLA-Cw6 positivity was 41% with no statistically significant difference in clinical response between HLA-Cw6-positive and HLA-Cw6-negative patients (P = 0.164). CONCLUSIONS: The presence of AUA was associated with treatment failure in this patient population; measurement of AUA may therefore be a candidate marker for personalized pharmacotherapy. The clinical utility of ustekinumab serum trough concentrations or HLA-Cw6 status determination remains less clear. Further exploration on the potential of measuring ustekinumab serum concentrations and other biomarkers in predicting therapy outcomes should be encouraged.

Facial Lichen Planopilaris: A Separate Entity or Not? A Case Series.

Lichen planopilaris (LPP) is an inflammatory hair disorder that is characterized by scarring hair loss, mostly affecting the vertex and parietal areas of the scalp. Frontal fibrosing alopecia (FFA) is considered a particular form of LPP, primarily affecting the hair follicles in the frontotemporal area of the scalp, with the hairline recession and eyebrow loss. There are case reports of FFA with concomitant involvement of facial vellus, characterized by roughening of the facial skin. We report five cases of facial vellus hair involvement in LPP, in the absence of other sites of disease activity. To the best of our knowledge, ours is the first report of LPP affecting the facial vellus hairs in the absence of FFA.

Comparison of Ex Vivo and In Vivo Dermoscopy in Dermatopathologic Evaluation of Skin Tumors.

IMPORTANCE: Ex vivo dermoscopy (EVD) can be a valuable tool in routine diagnostic dermatopathologic evaluation. OBJECTIVES: To compare in vivo dermoscopy (IVD) and EVD and to provide guidance for routine dermatopathologic evaluations. DESIGN, SETTING, AND PARTICIPANTS: This observational study collected 101 consecutive IVD and EVD images of skin tumors from a private dermatology practice from March 1 to September 30, 2013. Four observers (3 dermatologists and 1 dermatopathologist) blinded to the histopathologic diagnoses independently scored and compared the colors, structures, and vessels of EVD images with those of the corresponding IVD images. Data were analyzed from January 1 to March 31, 2014. MAIN OUTCOMES AND MEASURES: Concordance between the EVD and IVD images and gain or loss of colors, structures, and vessels on EVD relative to IVD images. RESULTS: The final analysis included 404 observations of 101 images. The EVD image was generally similar to the corresponding IVD image but clearly darker, with new areas of blue in 130 of 404 observations (32.2%) and white in 100 of 404 observations (24.8%) and loss of red in 283 of 404 observations (70.0%). Most structures were well preserved. New structureless areas were found in 78 of 404 observations of EVD images (19.3%), and new crystalline structures were detected in 68 of 404 observations of EVD images (16.8%). On EVD images, squames and crusts were lost in 56 of 404 observations (13.9%) and 43 of 404 observations (10.6%), respectively. Blood vessels were lost in 142 of 404 observations of EVD images (35.1%). CONCLUSIONS AND RELEVANCE: The EVD image is an important new tool in dermatopathology and may give direction to targeted tissue processing and examination of skin tumors.